Monthly Archives: February 2012

This post is written by new Wright on Health blogging partner Nicole Fisher. Nicole is the Senior Policy Director at Health Systems Innovation Network where she does health economic and policy analyses generally focusing on Medicare, Medicaid and health reform. She also is a current PhD student at the University of North Carolina in the Health Policy and Management Department and writes on a variety of health care topics for several think tanks and websites. Nicole also has a masters degree in Public Policy from the University of Chicago and an undergraduate degree from the University of Missouri.
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With less than two years before state-based health insurance exchanges are to be operational, most state legislators and health policy experts still cannot come to an agreement on how to set up, operate, monitor or fund state exchanges. However, despite persistent confusion and concerns surrounding health insurance exchanges, the White House recently released a report on the progress of state-level health insurance exchanges. This publication took a favorable and possibly misleading view of the headway being made by states that are creating their online insurance marketplaces.

The Administration claimed that there are currently 28 states making great progress in establishing an exchange. Even if that were true, this indicates that 22 states -or about 40 percent- are refusing to comply with the Patient Protection and Affordable Care Act (PPACA).

Although the report does not lie, it also doesn’t exactly accurately portray where most states stand either… The Administration chose to furtively count states that fall into a grey area as making progress toward setting up an exchange. Many states have, in actuality, refrained from any legislative activity or the state legislature has merely set up a committee to “study options”. What this really indicates is that many states are purposefully not complying with the PPACA mandate to create an exchange, but also managing not to violate it so that they are allowed to keep federal funding, at least until the January 2014 deadline.

Figure 1 below illustrates exchange status more accurately by categorizing, into six categories, where states stand in terms of state-based exchange implementation. These classifications range from states that have already established an exchange to states who have taken legislative action not to create an exchange.

As the White House rightly exhibited, there are a few states that have made significant progress in setting up an exchange and benefited greatly from the extra federal dollars. Rhode Island recently received an additional $60 million from the federal government for their collaboration with Massachusetts and Vermont to improve system integration associated with health insurance exchanges. California, Colorado and Washington have also seen legislation signed into law following the passage of PPACA to implement a state health insurance exchange.

In contrast, based on a February 2012 analysis of all states, Figure 1 shows that five states have no legislative activity whatsoever related to a health care exchange; and several states such as Wisconsin, Louisiana and Florida not only rejected setting up an exchange, but returned the grant money bestowed to them from the federal government to establish an exchange. More common scenarios, and where Figure 1 differs from the White House, are that many states are merely “investigating options” or allowing an exchange bill to bounce around legislative committees but never go to a vote. These alternatives allow states to keep their federal funding, but take no action to set up an exchange.

For example, the state of North Carolina had a Republican majority who drafted an exchange bill. That bill, however, was moved from one committee to another over than span of months for “reading.” For the past year, that same bill hasn’t seen the light of day and the Republican majority has no intention of ever letting it. This way, the state is allowed to spend federal exchange dollars, but not actually carry out the Administration’s plans. New Hampshire also had an exchange bill written, but after passing the Senate, that bill failed to pass the House of Representatives. In doing so, New Hampshire was allowed to keep exchange funding, but use the stalemate as a way of not having to revisit the idea of exchange implementation until a future session. South Carolina on the other hand used the original Exchange Planning Grant from the federal government to create an exploratory committee on exchanges, but decided after its creation that no legislation should be written.

As the economic crisis continues, unemployment remains high and the Supreme Court prepares to hear oral arguments for various provisions of PPACA in March, the number of states moving forward with enacting an exchange should become stagnant. This could further undermine the “progress” being made by states that fall into the grey area. Regardless, whether states are stalling efforts to create state-level exchanges, “studying” alternative options and costs, or flat out rejecting the idea, it’s safe to say that the optimism demonstrated in the White House report is a bit rosier than the real state of state-level health insurance exchanges.

Things are about to get a lot more fair and balanced here at Wright on Health. It is my pleasure to announce that Nicole Fisher will be blogging in this space on what will hopefully be a regular basis. Nicole Fisher is the Senior Policy Director at Health Systems Innovation Network where she does health economic and policy analyses generally focusing on Medicare, Medicaid and health reform. She also is a current PhD student at the University of North Carolina in the Department of Health Policy and Management and writes on a variety of health care topics for several think tanks and websites.

Before pursuing her PhD in health policy Nicole obtained her Masters degree in Public Policy from the University of Chicago and her undergraduate degree from the University of Missouri. Her health care and policy work at those institutions had an emphasis on underserved populations, women’s and children’s issues.

The great thing about Nicole is that her views are to the right of my own. I’m excited about what that means for the blog. First, I hope it will attract a more diverse audience, and will prompt readers to get more engaged with comments. After all, Nicole and I don’t see eye-to-eye on most things, so one of us is likely to ruffle your feathers a little bit–or at least make you think about things differently. I think that’s important. People (myself included) have a tendency to surround themselves with others who think like they do, and that can be problematic. To embrace that, we’re thinking about doing a count-counterpoint series among other things, so stay tuned. Come back tomorrow, when Nicole’s first post is scheduled to appear, and spread the word using the various links to Facebook, Twitter and other social media to get the public engaged in these important issues.

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Opposition to health reform tends to come from those who are happy with the way things are and worried that change represents nothing more than the risk of losing what they already have. That’s precisely why the opposition rhetoric focused on “death panels” and “rationing” of care. Stories were told of how our health care system would become like the Canadian system where people die waiting in line for care. Such stories are vastly overblown, I assure you, having spoken with a fair number of Canadians who love their system and who, having come to the U.S. for one reason or another, are appalled at the convoluted way our system works.

But for those who fear that expanding health insurance coverage means long lines and wait-lists, Chapin White of the Center for Studying Health Systems Change has good news: Expanding coverage doesn’t necessarily mean that overall health care utilization increases. Instead, that depends on how much physicians are reimbursed. Pay doctors more and, it seems, we visit them more often (rather, they are willing to see us more often).

The Affordable Care Act expands coverage, but it doesn’t dramatically increase physician reimbursement rates. Ergo, we’re not likely to see large increases in physician utilization, and that means we won’t likely see a lot of rationing or wait-listing. Sadly, it means that many of the newly insured will have a hard time finding someone to care for them. Medicaid doesn’t pay doctors well. It never has. So, a lot of doctors don’t accept Medicaid patients. Giving low-income uninsured persons Medicaid coverage may shield them from high out-of-pocket expenses, but it doesn’t mean they will be able to go to any doctor they choose. So, the rationing that exists will be the rationing that largely remains from the stratified system we have had for decades, where those with private coverage get more than they need, while those with public coverage often fail to get enough. That is not new rationing. It is the status quo.

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The doctor-patient relationship, like any good relationship, is built on trust. After all, the patient is naturally at the mercy of their physician in most cases, because the physician is the expert. Sure, the patient should have the ultimate say in their care, but the information they are basing their decisions on typically comes from the physician, and they must trust that what they are being told is the truth. Unfortunately, a recent study by Lisa Iezzoni and colleagues finds that doctors aren’t always so honest with their patients.

In a survey of a representative sample of physicians, more than a third of doctors fail to completely agree with the statement “Physicians should disclose all significant medical errors to affected patients.” Nearly one-in-five fail to completely agree with the statement “Physicians should never tell a patient something that is not true.” That’s right, more than 17% of doctors felt that there were times when it was okay to lie to patients.

As for their actual behavior, 11% of physicians reported rarely, sometimes, or often (in contrast to never) telling a patient something that was not true, and 55% reported rarely, sometimes, or often describing a patient’s prognosis in a more positive manner than warranted. Admittedly, the latter case could be perceived as compassionate rather than dishonest depending on the circumstances.

What are we, as patients, to make of these findings? Well, on the one hand, the truth could be even worse than the results suggest because of “social acceptability bias.” In other words, doctors know that admitting to being dishonest isn’t the “right” answer to give, so they may ironically be dishonest about reporting their dishonesty. At the same time, the framing of the results may actually be misleading. By taking four responses (never, rarely, sometimes, and often) and grouping them into two categories (never vs. not never), important information is obscured. If most of the doctors who admit to lying are in the “rarely” category, perhaps that’s not so bad. If, on the other hand, most of them reported lying “often” that’s a little scary. Unfortunately, the way the data are presented, it isn’t clear which is the case. I think it would have been better to put two responses in each category so that “never” and “rarely” were combined and compared to “sometimes” and “often.”

My sense is that doctors, like all people, sometimes lie–perhaps more often by omission rather than commission–but that we should not be too worried about the results of this survey. Don’t assume your doctor is lying to you or that they are always being honest. That’s what second opinions are for.

Would more Americans support health reform is President Obama was white? According to a recent study conducted by Michael Henderson of the University of Mississippi and D. Sunshine Hillygus of Duke University, the answer is yes. The researchers modeled changes in support of health reform between 2008 and 2010, and what they found was striking. According to Henderson and Hillygus, among a group who supported health reform in 2008, whites were 19 percentage points more likely than blacks to be opposed to health reform by 2010. Keep in mind that this race effect is seen after controlling for party affiliation and political ideology. It also controls for income, age, gender, education, and worry over the cost of health care. Said another way, this race effect isn’t likely to be biased by the usual suspects.

Moreover, the researchers included a measure of racial resentment, and those with the highest levels of racial resentment were 29 percentage points more likely to go from supporting health reform in 2008 to opposing it in 2010. These effects are additive. That means that whites with high levels of racial resentment are a whopping 48 percentage points more likely to switch from supporting to opposing health reform in the course of two years, compared to their black counterparts with low levels of racial resentment. That’s a big deal, to paraphrase Joe Biden for a general audience.

That doesn’t mean that people’s concerns over health reform aren’t legitimate. It’s perfectly reasonable to be opposed to an individual mandate, for example. The question opponents of health reform need to ask themselves, though, is how they would feel about the Affordable Care Act if the man who signed it into law looked like them. I don’t think opposition to reform would disappear–after all, when Clinton tried to pass reform legislation in the 1990s, it failed spectacularly–but I do think the tone of the debate would have been a little different, and I don’t think we’d be seeing the continued opposition after passage that we’re seeing now. Just look to the recent past for proof: Medicare Part D is all the evidence you need that a white President can pass a budget-busting piece of legislation without so much as a second glance from the American people. If George W. Bush had been black, perhaps America’s seniors would still be without adequate prescription drug coverage.

If you’re at all familiar with opinion polls, you know a few things: How the questions are asked matters; The results are always within a certain margin of error thanks to probability sampling; and there are always some people who profess to have no opinion on the question being asked. When we interpret the results of polls, it’s easy to keep the margin of error in mind, and it’s not even that difficult to assess the impact of question wording by comparing the results from differently worded polls that are asking about the same thing. No, the real challenge is figuring out what those undecideds are actually thinking. A little example shows why this can be so important.

Let’s say a poll asks respondents about their support of health reform. Now imagine two sets of results, both with a margin of error of +/- 3%.

In this case, we clearly want to know what the undecided respondents are thinking, because there are so many of them. The results simply aren’t very informative when we only know what half of people are thinking. Now, consider a case where we might be inclined to ignore this lack of opinion:

In this case, we would consider the public evenly divided on the issue, because the difference of 3% is well within our combined margin of error. We probably wouldn’t think much of the 5% with no opinion, although the reality is that how that group broke out if people were forced to choose one position or the other, could make a difference. If all 5% went to the support camp, we’d still have a statistical tie. If they broke for the opposition, the difference between the two groups would no longer overlap. The undecideds matter.

Fortunately, there’s something that researchers can do to get around this. As Adam Berinsky and Michele Margolis from MIT write in a recent issue of the Journal of Health Politics, Policy, and Law, it is possible to impute the opinions of those who profess not to have an opinion. Here’s how it works: Most people don’t answer “no opinion” to every question. So, you use their responses to the questions they did answer to match them up with other respondents who answered those questions the same way they did. Then you look at the way those people answered the question that the others expressed no opinion on. That gives you a sense of how they would have answered the question if they had done so. Make sense?

Here’s a silly example: Let’s say you asked people three questions about which foods they liked to eat. First, you ask if they like lettuce. 80% say yes, and 20% say no. Then you ask if they like cheese. 50% say yes, and 50% say no. Then you ask if they like hamburger. 40% say yes, 20% say no, and 40% have no opinion. When you look at the data, you see that the 40% with no opinion all like lettuce and dislike cheese. Others in the sample who like lettuce and dislike cheese report that they dislike hamburger (it turns out they are strict vegetarians). Therefore, it’s not a certainty, but there’s a good chance that the folks with no opinion actually dislike hamburgers. They may also be vegetarians who answered no opinion because they felt the question wasn’t relevant to them, for example. Make better sense? Good.

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I’m venturing away from health policy for a moment and into the world of politics more generally, and with that I feel the need to make it clear that I am not endorsing any candidate through this post. Rather, I want to pose the question: How wealthy should America’s president be? The fact of the matter is that no one with truly modest finances has ever actually been elected president. That’s because getting elected requires education, intelligence, work and leadership experience, connections, and campaign finances. The positive association between these things and wealth is generally strong. So, a wealthy president is likely to excel in at least some of these other areas that we consider integral to effective executive leadership.

But presidents are also supposed to be accountable to the public. That’s why they are elected, not appointed. That’s why we have term limits, not dictatorships.Yet how accountable can someone be when they cannot even begin to relate to the average member of the populace? In other words, is there a point at which a candidate’s wealth stops being an indication of their fitness for the office and starts becoming an indication that they are out of touch with mainstream America? Again, all presidents are “different” from the majority of us, and in that sense, they are all at least a little bit out of touch. But might some be far more out of touch than others, and might wealth be a good way to tell them apart?

If so, Mitt Romney looks to be so out of touch with America that he ought to just pick up and move to the colony that Newt Gingrich wants us to build on the moon. According to a recent Associated Press article by Connie Cass, Mitt Romney’s wealth is approximately double that of Richard Nixon’s, Gerald Ford’s, Jimmy Carter’s, Ronald Reagan’s, George H.W. Bush’s, Bill Clinton’s, George W. Bush’s, and Barack Obama’s, combined. Considering for a moment that Obama alone is worth something like $5 million, that’s pretty astounding.

Indeed, Romney may be worth up to $250 million. There is discussion of the fact that even though he no longer works, he earns more in a day from capital gains (investment income) than most Americans make in a year. I’m afraid that he can no more identify with my financial situation–or that of tens of millions of Americans who have it far worse than me–than I or they can identify with his financial situation. Seriously. I can’t even begin to know what I would do if I made over $50,000 a day. I wouldn’t have to work, that’s for sure. Perhaps I’d run for president.